APPLICATION
(For use of this form, see DMNA Reg 672-1. Proponent is MNHS-AD)
SECTION I PERSONAL DATA
______(date) From:______(first name) (middle initial) (last name) ______(current/former rank, *Social Security number, and unit)
*Home Address: ______
______
*Phone Number/E-mail Address: ______
If you are currently a member of one of the following, please place a check mark next to the appropriate component:
□ Army National Guard (ARNG) □ Air National Guard (ANG) □ Naval Militia (NM) □ New York Guard (NYG)
Please place a check mark along side of the award(s) you are requesting.
□ NEW YORK STATE CONSPICUOUS SERVICE STAR □ NEW YORK STATE MEDAL FOR MERIT
Have you previously been awarded the New York State Conspicuous Service Cross? □ Yes □ No If yes, when? Date ______
This is to certify I have reviewed the eligibility criteria in SECTION II for the award(s) I am requesting. I am forwarding herewith substantive documentation to support this request. Attached is a copy of Report of Separation from Active Duty (i.e. WD AGO 53-55, DD Form 214, etc.). This documentation will include my Honorable Discharge, list of awards or certificates or permanent orders for awards and will indicate current New York State citizenship while serving on federal active duty.
______Signature of Applicant or Posthumously Requested By REPLY TO: The Adjutant General Division of Military and Naval Affairs ATTN: MNHS-AD Latham New York 12110-3514
DMNA Form 106B-R (Front) (2 September 2008)
*Privacy Act and NY State Personal Privacy Protection Law information. See DMNA Reg 672-1 for details.
APPLICATION
SECTION II ELIGIBILITY CRITERIA
The general criteria for both awards require an individual to be:
1. A current New York State citizen OR 2. A New York State citizen while serving on federal active duty AND 3. A current or former full-time military person serving in the Armed Forces of the United States or allied forces for purposes other than training since 1917, Active, Active Guard/Reserve (AGR) excepted AND 4. Currently serving under honorable conditions or honorably discharged from active duty.
NEW YORK STATE MEDAL FOR MERIT NEW YORK STATE CONSPICUOUS SERVICE STAR
Recipient of at least one of the following: Recipient of at least one of the following:
1. Joint Service Commendation Medal 1. Distinguished Unit citation/Presidential Unit citation (Army/Navy 2. Army Commendation Medal Air Force) 3. Navy-Marine Corps Commendation Medal 2. Joint Meritorious Unit Award 4. Air Force Commendation Medal 3. Valorous Unit Award 5. Coast Guard Commendation Medal 4. Meritorious Unit Commendation (Navy-Marine Corps) 6. Aerial Achievement Medal 5. Navy Unit Commendation 7. Joint Service Achievement Medal 6. Meritorious Unit Commendation (Navy-Marine Corps) 8. Army Achievement Medal 7. Coast Guard Unit Commendation 9. Navy-Marine Corps Commendation Medal 8. Air Force Outstanding Unit Award 10. Air Force Achievement Medal 9. Air Force Organizational Excellence Award 11. Coast Guard Achievement Medal 10. Coast Guard Meritorious Unit Commendation 12. Gold Lifesaving Medal 11. Air Force Gallant Unit Citation 13. Silver Lifesaving Medal 12. Air Force Meritorious Unit Award
NOTE: All awards listed above with the exception of the 14. American Campaign Medal Presidential Unit Citation and Valorous Unit Award require 15. Asiatic-Pacific Campaign Medal additional evidence that award was made for combat participation. 16. European-African-Middle Eastern Campaign Medal 17. Korean Service Medal 18. Vietnam Service Medal 13. French Fourragere 19. Southwest Asia Service Medal 14. French Croix de Guerre (World War 1 and World War II) 20. Combat Action Ribbon 15. French Medal Militaire 21. Armed Forces Expeditionary Medal 16. Belgian Fourragere 22. Armed Forces Service Medal 17. Belgian Croix de Guerre 23. Combat Infantryman Badge 18. Luxembourg Croix de Guerre 24. Combat Medal Badge 19. Netherlands ORANGE lanyard 25. Navy Submarine Combat Patrol Insignia 20. Military Order of William (Netherlands) 26. Mariner’s Medal (Merchant Marine-World War II) 21. Croce al Merito di Guerra (Italy) 27. Merchant Marine Combat War (World War II) 22. Orden de Torre E Espada (Portugal) 28. Kosovo Service Medal 23. Philippine Republic Presidential Unit Citation (awarded prior to 1945 ) 29 Global War on Terrorism Expeditionary Medal 24. Republic of Korea Presidential Unit Citation 30. Marine Corps Expeditionary Medal 25. Chyssoun Aristion Andrias (Greece) 31 Navy Expeditionary Medal 26. Republic of Vietnam Gallantry Cross Unit Citation 32. Iraq Campaign Medal 33. Afghanistan Campaign Medal NOTE: Specifically excluded are the Army Superior Unit Award, 34. Combat Action Badge Navy “E” Award Ribbon, and the United States Merchant Marine 35. Army of Occupation Medal Gallant Ship Citation Ribbon. 36. Navy Occupation Service Medal 37. Korean Defense Service Medal
STANDARD: If you have already been awarded the New York State Conspicuous Service Cross, you are not authorized to apply for the New York State Medal for Merit.
DMNA Form 106B-R (Back) (2 September 2008)